2Psychiatrist, Ankara University Faculty of Medicine, Alcohol and Substance Abuse Treatment Unit, Ankara - Turkey
Objective: This study aimed to determine the relationship of relapse with the therapeutic factors in here-and-now focused group oriented interpersonal therapy of alcoholic patients.
Method: Fifty nine alcohol dependent male patients were selected from the patients receiving inpatient treatment form the study population. After the termination of the group therapy, each patient was administered Yalom’s 60-item therapeutic factor-Q-sort and they were followed for 6 months.
Results: The most valued therapeutic factors by the patients were existential factors, self-understanding, catharsis and family re-enactment. Difference between the ranks of therapeutic factors in the abstinent and the non-abstinent group was not statistically significant. The instillation of hope appeared in the tenth rank in the non-abstinent group and in the fifth rank in the abstinent group, and universality appeared in the eleventh rank in the non-abstinent and in the sixth rank in the abstinent group of patients.
Conclusion: Instillation of hope and universality are the two therapeutic factors that should be emphasized in alcoholic patient groups and also be studied on. Group context seems as an important factor for ordering of the therapeutic factors. Duration of hospitalization is an important factor on the outcome of treatment, remission.
It is usually reported that group psychotherapy has many advantages over individual psychotherapy in alcohol dependence treatment. Matano and Yalom (1) provided the details of therapeutic principles in alcoholic patient groups, especially focusing on here-and-now experience in an interactional context. They also underlined some dynamic processes related to alcohol dependence such as idealization and devaluation, defiance and dependency needs which could form problem situations to be held more hardly in individual psychotherapy. Critical issues concerning this have been identified as the group being a protective environment for the patient with fear of dependency and carrying a degree of freedom and support to behave in a controlled interpersonal context (2). Moreover, Tetra et al. (3) reinforced the importance of the psychotherapy.
In several studies, interpersonal problems have been found to be related to relapse in alcoholic patients (4-6); this also explains the importance of group oriented interpersonal therapy for alcoholic patients. There are examples of studies showing successful outcome of alcohol dependence with group oriented interpersonal therapy (3,7,8). However, few of them have sought to identify which of the therapeutic factors defined for interpersonal here-and-now focused group therapy are related to the outcome specificly.
Therapeutic factors in group psychotherapy defined by Yalom (9) previously are also valid for alcoholic patients’ therapy, namely, altruism, cohesiveness, universality, interpersonal learning-input, interpersonal learning-output, guidance, catharsis, identification, family re-enactment, self-understanding, instillation of hope and existential factors. In this respect, this study aimed to determine the relationship between the therapeutic factors and relapse after the treatment of alcoholic patients through group oriented interpersonal therapy.
Subjects were selected from patients receiving inpatient treatment for alcohol dependence. The exclusion criteria for group psychotherapy included the subjects with significantly impaired cognitive functions, psychotic disorder, personality disorders affecting general adaptation of the patient to a significant degree, a low level of motivation for treatment. Totally, eight group therapy periods have been completed for gathering data for this study. Fifty nine male patients formed sample of the study, all of whom had been diagnosed with alcohol dependence according to DSM-IV criteria.
Mean age of the study population was 42.4 (±7.7). Other demographic characteristics of the sample are shown in Table 1.
The study sample has undergone a structured treatment program including closed group oriented interpersonal therapy sessions, projective drawing, community meetings, sports hours and outdoor social activities and information giving about alcohol dependence. Total duration of hospitalization lasted 93.5 days (sd=23.3) on average.
Art therapy was done twice weekly and have lasted 2 hours. Community meetings were held three times a week, each of which have lasted about one hour. Every Monday morning, weekend activities were talked about and every friday afternoon, patients were asked about their weekend plans (after the first week of hospitalization patients were allowed to go out at weekends). Every week, there were two hours of sports and outdoor activities, and once a week, patients were encouraged to engage in social activities like going out for cinema, theatre, etc. Once a week, patients were informed about biological and psychological aspects of alcohol dependence. All the above mentioned treatment activities provided observation and information for group oriented interpersonal therapy sessions (10).
Group therapy sessions were conducted three times a week, each of which lasted 50±5 minutes. Total number of sessions was 25. One therapist and a co-therapist held the groups. The therapist was a highly experienced professional on addiction and group psychotherapy as well. Co-therapist was a psychiatry resident who attended the rotational program of the clinic, so the co-therapist could change for each group. In group therapy, Yalom’s here-and-now focused interactional therapy principles were applied. At the end of each session, the process was discussed with the observers (other members of the treatment team composed of a psychologist, two nurses and 4 or 5 sixth grade medical students).
After the termination of the group therapy, each patient was administered Yalom’s (9) 60-item therapeutic factor list using Q-sort technique. The patient was given a stack of random cards and asked to place a specified number of cards into seven piles labeled in the following manner:
1 least helpful (2 cards)
2 less helpful (6 cards)
3 barely helpful (12 cards)
4 helpful (20 cards)
5 very helpful (12 cards)
6 extremely helpful (6 cards)
7 most helpful (2 cards)
Every 5 item corresponded to a therapeutic factor. Factor scores were calculated by simply summing up corresponding scores of five items. Demographic information (age, educational level, marital status) was collected and total duration of hospitalization was also recorded.
After discharge, patients were followed monthly for at least 6 months. Since brief intervals of remission do not predict long-term recovery for alcohol use disorder (11), the stability of 6-month remissions was examined. Six-month remission period is considered predictive of long-term recovery (12). Patients who missed appointments were phoned to get information about the relapse or the remission situation. Outcome status was defined as remission or relapse in the first 6-month period. In this case, the state of relapse was assumed to be as drinking for 3 consecutive days. During the follow-up, only one patient was missed, so the procedure was completed by 58 subjects; 24 (41.4%) of whom have relapsed whereas 34 (58.6%) of them were in remission at the end of the 6 months.
Chi-square test was computed to analyze the relationship between educational background, marital status, occupational status and the outcome variable and to compare factor scores of different therapy groups. Moreover, Mann Whitney u test was applied to test the relationship between factor scores and the outcome. Median of each factor score was taken to make a rank arrangement of the therapeutic factors from the most helpful to the least helpful one. Significance level was taken as p<0.05.
No difference has been found between the outcome of patients with university degree and those with lower educational status according to chi-square analysis (χ2=0.000, p=0.984); 10 (58.8%) of the university-graduate patients and 24 (58.5%) of those with lower educational level were abstinent during the first 6 months after group therapy. Again no relationship was found between the marital status and being abstinent in the first 6 months (χ2=0.165, p=0.685); 11 (55.0%) of single or divorced or widowed group and 23 (60.5%) of the married were abstinent. Same was true for occupational status (p=0.640) in Fisher’s exact test: 2 of the 5 unemployed patients was in remission compared to 32 (60.4%) of the employed ones.
The score for each therapeutic factor was calculated by sum of ranks of the five representative items and according to this, the most valued therapeutic factors by the patients were existential factors, self-understanding, catharsis and family re-enactment (Table 2). Altruism and identification were the least valued factors. Ranks of therapeutic factors between the abstinent and the non-abstinent group were compared and no significant difference was found out between them except the instillation of hope which appeared in the tenth rank in the non-abstinent group and in the fifth rank in the abstinent group. Furthermore, universality appeared in the eleventh rank in the non-abstinent group, yet in the sixth rank in the abstinent group of patients. In Mann Whitney-utest, no significant relationship was found between the scores of the therapeutic factors and abstinence for the first 6 months after the group therapy (Table 2).
Chi-square results showed that values of therapeutic factors did not differ significantly among the eight groups (Table 3).
It was already asserted that interpersonal problems formed an important relapse precipitant in alcoholic patients (4-6), so it is also appropriate to think that group oriented interpersonal therapy may be the treatment of choice in these patients as demonstrated (7,13,14). However, it is also necessary to identify the group therapeutic factors which would work in terms of abstinence. This study was an endeavor to demonstrate this mentioned aspect of interactional here-and-now group therapy and to detect some methodological difficulties.
First, it can probably be concluded that none of the group therapeutic factor was specifically related to outcome in alcohol dependent patients. The reason may be that individual patient can get use of any therapeutic factor according to his specific needs as in any other patient groups as Yalom states (9). Individuality of the patient is actually one of the vital aspects considered in alcoholic group therapy, otherwise stigmatization and self-stigmatization of the alcohol dependent patient would be an important barrier in therapy. Therefore, alcoholic patients have more difficulties identifying and expressing their feelings (15).
Another explanation for the mentioned result may be that some nonspecific factors are involved in group therapy which determine the outcome. As Yalom states (9), the way of evaluating the therapeutic factors, as was done in this study, is thoroughly subjective and may be affected by many undefined variables, which is actually the case in many psycological and psychiatric studies. However, it should also be emphasized once more that group therapy sessions in this study were held in a highly structured environment by the same therapist.
Probably the most essential aspect of the evaluation for the results of this study would be to discuss the assessment instrument. It is not a scale allowing the patients to be free to choose or not to choose many items; they had to choose one item in a predetermined manner. Yalom also elaborates this point stating that the subjects’ task is a forced sort, which means that the least chosen items are not necessarily unimportant, but are, instead, less important relative to the others (9). Another handicap for the methodology here may be questionable validity of the assessment instrument as it is not adapted to Turkish culture. For future studies, it can be recommended that this instrument be validated by changing its ranking to a Likert type scale during the possible adoptation process.
On the other hand, existential factors, self-understanding and catharsis were the most valued factors by both the abstinent and the nonabstinent patients. This finding is very similar to another study conducted with alcoholic inpatients demonstrating cohesiveness in the third place differently (16); again one similar resultwas that altruism, identification and family re-enactment were the least valued therapeutic factors. Atbasoglu and Dogan (17) reported that interpersonal learning-input, existential factors and catharsis were the most valued therapeutic factors. Lovett and Lovett (16) discussed these findings as the results of patient characteristics rather than group experience. However, Atbasoglu and Dogan (17) reported that different therapeutic factors were present in Alcoholics’ Anonymous (AA) and in interpersonally oriented therapy groups. Moreover, in the latter study, the same therapist of the groups, Dogan involved in the present study run the therapeutic group, and consistence of our results with it shows that ordering of the therapeutic factors are actually dependent on the group context.
It is noticable that instillation of hope appeared in the eighth rank in the non-abstinent group and in the fifth rank in the abstinent group. Another study portrayed that optimism enhances individual coping-skills to balance patient’s lifestyle focusing on an abstinent way of life (18). It was already suggested that it seems effective to mobilize hope in substance abusing patients by utilizing recovered drug addicts (9). This result is likely to reflect the effect of recovery from depression which is usually comorbid with alcohol dependence. Instillation of hope may also be related with the level of self-efficacy of patients which is already shown to be relevant to outcome in alcoholic patients (19-21).
Universality appeared in the ninth rank in the non-abstinent group but in the sixth rank in the abstinent group of patients. In fact, universality factor which worked here is not the one that is based on alcohol dependence, but other human matters and this is especially paid attention to in the beginning sessions to construct an important aspect of group culture. As a matter of fact, none of the phrases representing universality are related to alcohol dependence and it is also unlikely for the patients to perceive these as related to drinking problems. This is actually the major difference between group oriented interpersonal therapies and self-help groups (17). However, it seems to work well in both.
Duration of hospitalization is an important factor on the outcome of treatment, remission. In this sample, duration of hospitalization was sufficiently long (93.5 days), which may be effective as group therapy on treatment outcomes. Some studies have suggested that long-term treatment of alcohol-dependent patients in a multi-professional team may not be much more successful than brief interventions (22). Moos et al. (23) studied the association between the duration of treatment and remission. Patients were compared in terms of their duration of hospitalization and classified as brief (1-8 weeks), moderate (9-26 weeks) and long-term (27 weeks or more) treatment. The findings highlight the limitations of a short duration of treatment in producing better alcohol-related outcomes. In future studies, association of treatment outcome with the duration of hospitalization will be studied according to therapeutic factors.
Definition of outcome in alcohol dependence is still being discussed. Precisely, the dichotomous state of abstinence versus nonabstinence is only one dimension of it. Quality of life seems to be a very important measure of alcohol dependence as it is considered to be related to drinking status as well as interpersonal problems and other social complications in alcohol abuse. Therefore, further studies are needed both to define the outcome status in alcohol dependence and to determine the therapeutic factors behind the outcome.
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2Psikiyatrist, Ankara Üniversitesi Tıp Fakültesi, Alkol ve Madde Bağımlılığı Tedavi Birimi, Ankara - Türkiye
Amaç: Bu çalışmanın amacı, “şimdi ve burada”ya odaklı kişilerarası yönelimli grup psikoterapisine katılan alkol bağımlısı hastalarda iyileştirici faktörlerle içmeme ilişkisini belirlemektir.
Yöntem: Çalışmanın örneklemini, yatarak tedavi gören 59 alkol bağımlısı erkek hasta oluşturmaktadır. Grup tedavisi tamamlandıktan sonra, her hastaya Yalom’un 60 maddelik iyileştirici faktör-Q sort tekniği uygulanmış ve hastalar 6 ay boyunca izlenmiştir.
Bulgular: Hastalar en değerli iyileştirici faktörler olarak, varoluşçu etmenler, kendini anlama, duygusal boşalım, birincil aile özelliğinin grupta yinelenmesi ve bunun onarıcı niteliğini belirtmişlerdir. Tekrar alkole başlayan ve içmemeyi sürdüren grup arasında, iyileştirici olan faktörlerin sırasında istististiksel açıdan fark yoktur. Umut aşılama faktörü tekrar alkole başlayan grupta onuncu sırada, içmemeyi sürdüren grupta ise beşinci sırada, evrensellik faktörü, tekrar alkole başlayan grupta onbirinci sırada, içmemeyi sürdüren grupta ise altıncı sırada sıralanmıştır.
Sonuç: Alkol bağımlısı hastalara yönelik grup tedavilerinde, iyileştirici iki faktör olarak umudun yerleştirilmesi ve evrensellik üzerinde durulmalı ve çalışılmalıdır. Grup dokusu iyileştirici faktörlerin belirlenmesinde önemli bir etmen olarak görülmektedir.